How to stay on top of exercise Whether you are looking to improve your fitness or regularly engage in sports, Dr Rob Andrews offers some instructive advice on medication for exercise. In people with healthy adrenals, exercise causes an increase in both natural hydrocortisone (cortisol) and fludrocortisone-like hormones, (mineralocorticoids). Other hormones, such as insulin, are also influenced by exercise. However, there has been little clinical research into how exercise directly affects people with Addison’s and how best to manage medication for exercise. How does exercise affect steroid levels? Cortisol is released from the start of exercise; how much relates to how intense the exercise is. Resistance training triggers smaller increases in cortisol than endurance, for example. Mineralocorticoids are also released during exercise, to help maintain fluid balance in the body. For people with Addison’s, the aim is to match these normal hormone-release patterns as closely as we can with extra medication. Inevitably, a certain amount of trial and error is involved in getting the right balance for the individual. My own research has shown that managing the post-exercise wind-down sensibly also has benefits, such as consuming a small amount of sugar/glucose (equivalent to about a Lucozade drink or a Jaffa cake) within an hour of strenuous exercise. Perhaps surprisingly, this helps the body maintain its energy stores and muscle balance. Are people with Addison's "different" when it comes to exercise? People with Addison’s generally need to follow the same basic principles of sensible exercise as those with healthy adrenals. You should stretch thoroughly before you commence exercise. You need to do a warm-up before and a warm-down after exercise. Take plenty of fluids during exercise and gradually increase the intensity of your exercise over time. Extra hydrocortisone or fludrocortisone is not usually needed for most exercise or fitness programmes, provided that you keep well hydrated and exercise within your own limits. On occasions when the exercise intensity is very high, the conditions particularly harsh (hot weather), or the exercise is prolonged (such as in competitive events like a marathon) then increases in medication may be required. Those who find themselves getting tense or overstrained during a competition or a training challenge, may find they need a little more medication to compensate, than would someone who is performing within their physical and emotional comfort zone. How much extra depends on the intensity and length of the exercise and whether it is a training day or competition day. The table below shows the guidelines I give to my patients. Individuals may find they need to adapt these slightly for their own exercise regime. Some example exercise programmes... Below are three timed examples, for medium and high intensity exercise on a typical medication regime. These are for an athlete, Jo, taking a standard adrenal replacement regime. Jo’s usual medication is 20mg hydrocortisone and 100mcg fludrocortisone per day. S/he splits the hydrocortisone 10/5/5 (10mg on waking, 5mg at lunchtime and 5mg at 5pm). Jo goes jogging for two hours, setting off at 10am. At 9.30am, half an hour before s/ he sets off, s/he takes an extra 5mg hydrocortisone, equivalent to a half dose extra. S/he takes the lunchtime and 5pm hydrocortisone doses as usual. Jo competes in a triathlon, starting at 10am, with an anticipated duration of 8 hours. S/he takes the usual 10mg hydrocortisone, 100mcg fludrocortisone on waking. At 9.30am s/he takes an extra 10mg hydrocortisone (1 dose extra). S/he takes 10mg hydrocortisone at lunchtime and 5pm (double dose). Six hours into the competition s/ he takes an extra 100mcg fludrocortisone (1 dose extra). Jo competes in a later triathlon, this time starting at 4pm. S/he takes the usual medication on waking and at lunchtime. At 3.30pm s/ he takes an extra 5mg hydrocortisone, followed by 10mg hydrocortisone (double dose) at 5pm. Six hours into the race s/he takes 100mcg fludrocortisone (1 dose extra). S/he finishes at midnight and – perhaps not surprisingly – feels unwell, so takes 5mg hydrocortisone (1 dose extra). Dr Rob Andrews This article was first published in the March 2018 edition of the ADSHG magazine.